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(This is the first part of a 4-part series. The following 3 pieces will discuss ADHD, addiction, and suicide prevention as covered in the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference.—Ed.)

Prior to the COVID-19 pandemic, the prevalence of mental illness was rising at an alarming rate. Since March 2020, it has only gotten worse.

 Between the increase in psychiatric conditions and the dearth of mental health care professionals, primary care providers (PCPs) are increasingly confronted with patients who are struggling with behavioral health conditions such as depression, attention-deficit/hyperactivity disorder (ADHD), insomnia, addiction, and suicidal ideation.

In response to this intersecting crisis of limited access to mental health specialists and rising rates of these disorders, the Department of Psychiatry at the University of Arizona College of Medicine in Tucson convened a committee of PCPs and psychiatrists with the charge to organize a fully virtual conference on Saturday, March 12, targeting the educational needs of physicians and allied health professionals working in primary care settings. “

Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care

” was created to provide PCPs with new and updated knowledge to enhance their clinical confidence and skills, improve comorbid medical comorbidities, and reduce the stigma of seeking treatment for mental illness.

Because the topics are wide-ranging and packed into 30- to 45-minute presentations, there are plenty of options for physicians, nurses, physician assistants, practicing psychiatrists, and resident physicians to gain valuable and applicable clinical knowledge.

In this series on the conference (for which participants may receive up to 5.5 CME hours), we will cover the presentations in 3 subsequent articles on ADHD in adults, screening for addiction, and suicide prevention.

 is professor and department chair of psychiatry at the University of Arizona College of Medicine. He is an expert in the fields of geriatric psychiatry, depression treatment, and suicide prevention. He is committed to educating health care providers about the principles of psychiatry and behavioral medicine. 

 is the communication and marketing specialist for the University of Arizona College of Medicine Department of Psychiatry.

1. Czeisler MÉ, Lane RI, Petrosky E, et al. 

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020

Primary care providers are increasingly seeing patients who are struggling with mental illness—how can they effectively assist these patients?

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

The Patient-Centered Outcomes Research Institute (PCORI) hosted a virtual panel on suicide prevention in youth and young adults, led by US Representatives Ashley Hinson (R-Iowa) and Jamie Raskin (D-Maryland).

PCORI, an independent nonprofit organization sanctioned by Congress in 2010, hosted the panel in order to present the current state of suicide prevention in this patient population and to discuss 2 PCORI-funded studies in progress that offer evidence-based strategies and initiatives to help prevent suicide. Introduced by Hinson, Raskin, and PCORI Executive Director Nakela L. Cook, MD, MPH, the panel shared alarming suicide statistics: Suicide is the second leading cause of death among 15- to 24-year-olds; overall suicide rates have increased by more than 30% since 2001; around 1 in 4 youths and young adults worldwide is experiencing clinically elevated depression; and 1 in 5 youth is experiencing clinically elevated anxiety, which is double the pre-pandemic rate. “These disturbing statistics demonstrate a compelling need for more evidence on effective suicide prevention strategies to help clinicians care for at-risk individuals,” Nakela said.

Following the opening remarks, Jill Harkavy-Friedman, PhD, vice president of research at the American Foundation for Suicide Prevention, discussed the social, psychosocial, biological, and environmental factors that often contribute to suicidal ideation in youths and young adults. “What we’ve learned through much of the research is that [individuals who die by suicide] have difficulty shifting gears and difficulty seeing strategies for coping,” Harkavy-Friedman said. “In essence, they feel tremendous pain. They feel helpless, they feel desperate, and they feel like they may be a burden to people and that nothing is ever going to change.”

Harkavy-Friedman added that these individuals do not have access to their normal coping mechanisms when they are in crisis, noting also that factors contributing to risk of suicide are not static, and that there is never a single cause of suicide. “I think it’s important for people to understand that 60% of people who die by suicide die on the first attempt,” she said. “So, we actually have to reach people before they get to the point of being aggressive or engaging in suicidal behavior.”

In order to reach these individuals earlier and more effectively, PCORI has funded research, including 2 studies in progress that were presented in the panel. Anna Radin, DrPH, MPH, applied research scientist in the Applied Research Division of St. Luke’s Health System, presented a study that compares 2 types of follow-up support for adolescents and adults who have screened positive for suicide risk in primary care clinics and emergency departments (EDs). The interventions examined include Safety Planning Intervention+ (SPI+), which involves support via phone calls, and Caring Contacts (CC), which involves support via a phone call and subsequent text messages or emails. In both cases, individuals receive personalized, non-demanding support in connection with a safety plan that they created while still in the hospital or clinic. Compared to patients who received usual care, those who received SPI+ were half as likely to engage in suicidal behavior and twice as likely to attend outpatient treatment, and those who received CC intervention were 44% less likely to have suicidal thoughts and 48% less likely to attempt suicide.

“I think the most important thing we’ve seen so far is really high levels of satisfaction with both interventions so far,” said Radin, who is also principal investigator on the study. “Of those that have completed an interim assessment of satisfaction, 99% of our participants reported that the follow-up phone calls they received through either intervention were helpful and would recommend them to a friend, and 95% of our participants reported that the text messages they received were helpful as well.”

The panel concluded with a discussion of the second study—presented by Joan R. Asarnow, PhD, ABPP, professor of psychiatry and biobehavioral sciences at UCLA and director of the UCLA Youth Stress and Mood Program—which also compared 2 evidence-based interventions for reducing suicide attempts. This study focuses on Safety-Acute(A), which is an ED crisis therapy session focused on patient safety (formerly known as Family Intervention for Suicide Prevention [FISP]), and the SAFETY-A + Coping Long-term with Active Suicide Program (CLASP), which is a series of brief therapeutic follow-up contacts that occur following discharge from the ED or hospital. Including 1516 youths aged 15 to 24 who presented to EDs with suicidal ideation and/or behavior in the study, the researchers randomly assign participants to either SAFETY-A or SAFETY-A + CLASP and then conduct assessments at the 3-, 6-, and 12-month marks. The aims of the study are to improve continuity of care within this patient population; to identify which patients may benefit from an approach to treatment that offers therapeutic contact both while they are in the ED and after they are discharged; and to help guide decision makers in the development of the services that will most effectively improve patient outcomes and achieve national goals for suicide prevention.

“Research confirms that we have effective suicide prevention strategies—and when we implement these strategies in our community settings, we see a reduction in deaths,” said Asarnow, who is also principal investigator on the study. “Although we can’t eliminate every single suicide, we can reduce them, and we can also reduce suicide attempts. But the problem is that proven suicide prevention strategies are too often unavailable to youth … in our communities.”

PCORI virtual briefing on suicide prevention in youth and young adults

. Patient-Centered Outcomes Research Institute. Panel presentation. February 23, 2022.

Comparing two ways to provide safety planning follow-up support for adults and teens at risk of suicide

. Patient-Centered Outcomes Research Institute. In progress.

Youth partners in care for suicide prevention (YPIC-SP)

Panelists presented 2 studies comparing evidence-based strategies for improved patient outcomes.

Researchers Address Youth Suicide Prevention in Virtual Panel

With our weekly Psychiatry & Society video taking a winter break, we bring back some of the greatest hits that are timely and continue to relate to current and uprising societal events of psychological interest. Take today’s story, for instance...

Daughters Overcoming Ecocide and Suicide (DOES)

." This video focused on the increased prevalence of suicide in Black teenage girls, which is especially poignant during Black History Month. At the end of January, we learned of the tragic suicide of Cheslie Kryst, a Black woman who was a former Miss USA. Although she was not a teenager, she was a young Black female. Hopefully, by now information has emerged from which we can learn more to prevent such suicides in Black girls and women.

What are you doing to honor Black History Month? Share your thoughts with us by emailing 

We need to talk about the startling suicide rates in Black girls and women...

Remembering Daughters and Suicide

My poem was inspired by the grief I am experiencing after the loss of my youngest son to suicide. Grief is common to all, but I never knew that grief existed on such a scale as this. Only after 2 years am I able to begin addressing it. I am grateful and honored to be in the care of my psychiatrist, Melanie Conway, MD, who is helping me navigate this devastation. Cruelly enough, I was a psychiatric RN working in an acute care psychiatric hospital for adolescents when this tragedy occurred.

The sculpture, “Melancholy” by Albert Gyorgy, was a great inspiration to me, as well. I did not know of its existence until someone asked me how I was feeling shortly after losing my son. My answer was: “like there’s a 14-inch hole through the middle of me.” When I saw this sculpture for the first time, I was speechless.

I used the phrase, “God sees around the bend,” with my sons as they were growing up, hoping that the knowledge of this would be of comfort to them as it is to me. It was a pleasant happening that my poem ended with this phrase.

I am an adolescent psychiatric RN who is currently in school to obtain my master’s degree in psychiatric/mental health nursing. With this education and accreditation, I will continue to work with adolescents in psychiatric crisis in my own practice. I have used and will continue to use 

 as a resource in my profession, as I have gained many insights from it in my personal and professional life.

The world spun on without slowing that day

Like a merry-go-round I tried slowing it down

I now lifted the edge of my hand from my heart

But I noticed a scar beginning to form
that I had not noticed before

I’ll always wish I hadn’t been chosen

An adolescent psychiatric RN shares “Heavy Damage,” a poem about managing grief after losing a loved one to suicide.

Grief After Suicide

Suicide in late life constitutes a major public health concern. In 2019, the Centers for Disease Control and Prevention (CDC) reported that the suicide rate for all ages in the United States was 14.5/100,000. Middle-aged and older adults have higher rates of suicide than their younger counterparts (19.41/100,000 for individuals aged 55 to 64), and the highest rate of suicide remains for older males (39.9/100,000 for males aged 75 and older).

 Despite the alarmingly high rates, psychosocial interventions for this population are understudied and urgently needed.

Mobile devices provide a unique and powerful opportunity to deliver interventions to suicidal individuals during periods of increased suicide risk.

 With the current COVID-19 pandemic, reliance on digital health technology is growing, and developing targeted interventions that can be used remotely by older adults during times of emotional crisis is of paramount importance.

To establish effective psychosocial interventions, risk factors for late-life suicide must be examined. Sociodemographic and clinical factors that are more commonly found in middle-aged and older individuals (eg, widowhood, cognitive decline, etc) play an important role in suicide risk. Understanding the complex interaction of these late-life occurrences can guide efforts in designing preventative interventions.

According to the CDC, middle-aged and older adults account for the highest number of suicides compared to younger populations. In 2018, adults aged 65 and older were reported to make up 16% of the US population, but were responsible for 18.8% of suicides.

 While there are an estimated 25 suicide attempts for every completed suicide in the general population, approximately 1 in 4 suicide attempts results in death for older adults.

 Gender, race, and ethnicity also influence suicide risk and behavior. Women consistently account for a higher number of suicide attempts than men. There are 3 female attempts for each male attempt, yet an estimated 3.6 males die by suicide for every 1 female death. This discrepancy is attributed to the difference in method, because men often use more lethal methods when attempting suicide.

 In comparison to other racial and ethnic groups, non-Hispanic American Indian/Alaska Native and non-Hispanic white people account for the highest rates of suicide at 22.3 and 17.6/100,000, respectively.

Cognitive Functioning and Physical Illness

As many as 1 in 9 older adults suffer from some form of cognitive impairment.

 Cognitive impairment is often responsible for reducing decision-making capacity and affecting emotion regulation abilities, potentially contributing to suicidal ideation and behavior.

 Discrepancies in literature regarding suicide risk and cognitive impairment suggest that dementia can either be a risk factor or a protective factor depending on the progression and severity of symptoms.

 However, a review on suicide risk and Alzheimer disease found that Alzheimer disease is associated with a moderate suicide risk in older adults, even several years after diagnosis.

Physical illness and functional disability in late life are also strongly associated with suicide. In a cohort study by Erlangsen and colleagues,

 investigators found that certain cancers and liver disease, specifically, are most closely associated with suicidal outcomes. Despite strong associations found in research, reviewers of the literature advise caution when using physical illness to determine risk, many noting that identifying physical illness does not serve as a predictor for suicide, nor does quantifying the severity of symptoms.

Psychiatric Illness and Suicidal Behavior

Psychiatric illness is noted in up to 97% of late-life suicides, with major depression cited as the most strongly associated psychiatric disorder.

 Retrospective analysis of psychiatric illness and suicide mortalities in older adults in Denmark highlight recurrent depression as contributing to the highest rate of suicides in adults aged 60 and older, followed closely by other affective disorders and reaction to stress/adjustment disorders. This risk was significantly increased for individuals who were hospitalized for any type of psychiatric disorder, with hospitalized psychiatric illness accounting for 22.3% of male suicides aged 60 and older.

One of the predictors of suicidal behavior is suicidal ideation, especially active suicidal ideation with intent or plan. However, in older adults who are seeking aging services, even passive suicidal ideation is an indicator of suicide risk.

 Despite the elevated number of late-life suicides, suicidal older adults often go undetected due to lower rates of reporting,

 especially in primary care where older adults most likely seek medical treatment. This information highlights the need for increased identification strategies, as well as enhanced efforts to prevent the onset of suicidal ideation given the high mortality rate in late-life suicide attempters.

Interpersonal losses including widowhood or death of friends and family are commonplace in advancement of age. The accompanying stress, sense of loneliness, and social disconnection in response to loss is associated with elevated suicide risk, especially within the first year after the death of a close relative.

 Passive and active suicidal thoughts are particularly common among older adults in long-term care facilities, and social isolation and loneliness are some of the most frequently reported bases for suicidal thoughts.

 The relationship between perceived social support and psychiatric illness, most notably depression, is strong even when controlling for other factors, such as negative affectivity and overreporting of experiences.

 This points toward a need for more dynamic psychosocial interventions.

Existing Psychosocial Interventions for Suicide Prevention

Current randomized, controlled trials (RCTs) that evaluate psychosocial interventions for older adults are typically developed to address depression or other affective disorders in young adults and are not specifically targeted toward suicidality.

 Of the few published RCTs that measure suicidal ideation as a primary outcome in older adults, the intervention and assessment methods are diverse. Conwell

 investigated the effect of a peer companionship program on socially disconnected older adults, but saw no significant difference in suicidal ideation outcomes between the treatment and control groups. Two studies, conducted by Ecker

 evaluated adaptations of CBT on veterans with suicidal ideation. The first study was a 4-month brief cognitive behavioral therapy (CBT), and the second was CBT for depression compared against 2 other evidence-based psychotherapies. Both authors reported a reduction in suicidal ideation in the CBT/bCBT groups compared to control groups.

 examined suicidal ideation as a primary outcome in tests of problem-solving therapy in older adult populations. These studies both saw significant reductions in suicidal ideation in the treatment groups; however, 1 study tailored the intervention toward older adults with depression and executive dysfunction, and the other targeted subjects with functional disability, making the interventions difficult to compare.

 investigated the effects of problem adaptation therapy (PATH) on suicidal ideation, an intervention that utilizes emotion-regulation techniques and compensatory strategies in older adults with depression and cognitive impairment. The authors saw a reduction in suicidality in the PATH participants, but the reduction was not significantly different from the supportive therapy control group.

The samples in the aforementioned studies represent specific populations (ie, veterans with medical illness, older adults with functional disabilities), and are not representative of the general older adult population. The heterogeneity of the interventions creates difficulty in both between-study comparisons and generalizability to the general population. Moreover, these studies often exclude those who express active suicidal ideation, leaving out those who are at greater risk of suicide. The results are promising; however, it is important that findings be replicated with larger and more representative samples to more accurately examine the effectiveness and promote generalizability of the interventions.

The onset of the COVID-19 pandemic and the associated policies have the potential to exacerbate the severity of the previously identified risk factors for suicide in older adults. Social-distancing guidelines, stress, and limited access to health care may contribute to increased feelings of isolation and loneliness, worsening of cognitive and functional abilities, and intensification of symptoms of psychiatric disorders.

 Technology offers the opportunity to alleviate logistical barriers to receiving clinical interventions for older adults who may have difficulty adhering to treatment. As the reliance on telehealth increases, more thorough investigation into remote psychosocial intervention methods targeted specifically for this population is particularly essential.

Literature on the role of technology treatment for suicide prevention in older adults is sparse. Preliminary findings available on feasibility and acceptability of technology-based mobile interventions suggest promising effects of improvement, but further testing is needed.

 In a review of mobile health technology for suicide prevention, one intervention, Virtual Hope Box (VHB), was tested in middle-aged adults. The study recruited both young and middle-aged veterans with a mean age of 46 years old and tested an augmentation of CBT using smartphone capabilities to enhance and personalize the experience with a “hope box.” The study evaluated the effect of the application on intensity of suicidal ideation and importance of reasons for living, but the results yielded no statistically significant treatment effect on these outcomes between the treatment and control groups.

Our research at the Emotion, Cognition, and Psychotherapy Lab at Weill Cornell Medicine aims to reduce suicide risk by employing a simplified, personalized, and easy-to-use mobile intervention. WellPATH is a tablet application that focuses on emotion regulation strategies (specifically, cognitive reappraisal strategies, which focus on seeing a situation from a different perspective) to reduce negative emotions associated with increased suicide risk. It is a personalized, mainly standalone, mobile intervention that incorporates patient-specific techniques that can be accessed when the patient is faced with negative emotions. The patient and WellPATH interventionist identify situations, problems, or concerns that trigger intense negative emotions that may lead to increased suicidal ideation or behavior and develop personalized cognitive reappraisal strategies to reduce the intense negative emotions.

Preliminary results indicate that patients are able to utilize the user-friendly interface with ease and are highly satisfied with the support provided by WellPATH.

 The WellPATH application takes into consideration characteristics unique to older adults and offers immediate access to an intervention that is easy to use. It addresses the need for a mobile suicide prevention intervention for middle-aged and older adults at high suicide risk, which is particularly germane, given the increased reliance on telehealth.

The topic of suicide in older adults requires greater consideration. Identification of risk factors is valuable in understanding elder suicidality; however, further attention is encouraged for the development and evaluation of effective interventions tailored to older adults. The few psychosocial interventions mentioned show overall promising results, but unfortunately, there is little available data beyond what has been described. The novel WellPATH tablet application has the opportunity to provide relief to individuals at high risk of suicide by offering an immediate intervention to patients in their actual environment. With the rapid increase in population of middle-aged and older adults, the continued exploration of adaptive preventative interventions is essential for safeguarding the well-being of this increasingly vulnerable population.

 is a research assistant in the Weill Cornell Medicine Kiosses Lab. 

is associate professor of psychology in clinical psychiatry at Weill Cornell Medical College; associate attending psychologist at New York-Presbyterian Hospital; and primary investigator in the Weill Cornell Medicine Kiosses Lab.

1. Fatal injury reports, national, regional and state, 1981-2019. Centers for Disease Control and Prevention. 2019. Accessed January 10, 2022. 

Smartphones, sensors, and machine learning to advance real-time prediction and interventions for suicide prevention: a review of current progress and next steps

4. About underlying cause of death, 1999-2020. CDC Wonder Online Database. 2021. Accessed January 10, 2022. 

https://suicidology.org/wp-content/uploads/2020/02/2018datapgsv2_Final.pdf

7. Disparities in suicide. Centers for Disease Control and Prevention. 2019. Accessed January 10, 2022. 

https://www.cdc.gov/suicide/facts/disparities-in-suicide.html

8. Subjective cognitive decline—a public health issue. Centers for Disease Control and Prevention. 2019. Accessed January 10, 2022. 

https://www.cdc.gov/aging/aginginfo/subjective-cognitive-decline-brief.html

9. Kiosses DN, Ravdin LD, Gross JJ, et al. 

Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial

Hospital-diagnosed dementia and suicide: a longitudinal study using prospective, nationwide register data

11. Serafini G, Calcagno P, Lester D, et al. 

Suicide risk in Alzheimer's disease: a systematic review

Physical diseases as predictors of suicide in older adults: a nationwide, register-based cohort study

13. Fässberg MM, Cheung G, Canetto SS, et al. 

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

The impact of psychiatric illness on suicide: differences by diagnosis of disorders and by sex and age of subjects

15. Van Orden KA, O’Riley AA, Simning A, Podgorski C, Richardson TM, Conwell Y. 

Passive suicide ideation: An indicator of risk among older adults seeking aging services?

Suicide and suicide prevention in later life

17. Mogensen H, Möller J, Hultin H, et al. 

Death of a close relative and the risk of suicide in Sweden-a large scale register-based case-crossover study

. 2016;11(10):e0164274. Published 2016 Oct 11.

18. Lutz J, Van Orden KA, Bruce ML, et al. 

Social disconnection in late life suicide: an NIMH workshop on state of the research in identifying mechanisms, treatment targets, and interventions

Suicide risk in long-term care facilities: a systematic review

Social support, health, and well-being among the elderly: what is the role of negative affectivity?

A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people

22. Conwell Y, Van Orden KA, Stone DM, et al. 

Peer companionship for mental health of older adults in primary care: a pragmatic, nonblinded, parallel-group, randomized controlled trial

23. Ecker AH, Johnson AL, Sansgiry S, et al. 

Brief cognitive behavioral therapy reduces suicidal ideation in veterans with chronic illnesses

24. Kumpula MJ, Wagner HR, Dedert EA, et al. 

An evaluation of the effectiveness of evidence-based psychotherapies for depression to reduce suicidal ideation among male and female veterans

25. Gustavson KA, Alexopoulos GS, Niu GC, et al. 

Problem-solving therapy reduces suicidal ideation in depressed older adults with executive dysfunction

Improvements in functional disability after psychotherapy for depression are associated with reduced suicide ideation among older adults

27. Sheffler JL, Joiner TE, Sachs-Ericsson NJ. 

The interpersonal and psychological impacts of COVID-19 on risk for late-life suicide

28. Beard C, Ramadurai R, McHugh RK, et al. 

HabitWorks: development of a CBM-I smartphone app to augment and extend acute treatment

29. Bush NE, Smolenski DJ, Denneson LM, et al. 

A virtual hope box: randomized controlled trial of a smartphone app for emotional regulation and coping with distress

30. Kiosses DN, Monkovic J, Stern A, et al. 

An emotion regulation table app for middle-aged and older adults at high suicide risk: feasibility, acceptability, and two case studies

Recent updates in suicide prevention interventions for older adults and how a novel tablet application may provide relief to individuals at high risk of suicide.

Suicide in Older Adults: Advances and the Role of Technology in Treatment

According to a new analysis, the annual rate of 

 attempts among US adults increased 17% from 2008 to 2019.

 Furthermore, the study showed that the rate of patients who were suicidal and did not know how to seek treatment more than doubled in the same time period. The findings highlighted the sociodemographic factors associated with increased risk of suicide attempts, and the pressing need to improve accessibility and social acceptability of care, as well as suicide prevention efforts.

Tanner J. Bommersbach, MD, MPH, and colleagues conducted a cross-sectional analysis of nationally representative data taken from the 

(NSDUH) from 2008 to 2019 to estimate annual rates of suicide attempts and use of mental health services by US adults.

For years, suicide has been one of the most common causes of death in the US, and it has increased by more than 60% since 1999. However, Bommersbach noted a “small but growing” number of decedents from suicide had contact with health services in the 12 months prior to their deaths. A recent systematic review and meta-analysis using data from 2000 to 2017 showed inpatient mental health stay (18.3%), outpatient mental health services (26.1%), and contact with both services (25.7%) were becoming more common among people who eventually suicided.

Bommersbach colleagues sought to understand the use of care among those who have only attempted suicide to inform prevention efforts.

“Suicide attempts are the single most important 

and the risk factor most likely to precipitate contact with the health care system,” they wrote. “Because the most effective suicide prevention approaches rely on identifying and treating individuals at high risk for suicide, suicide attempts offer a valuable opportunity to intervene at a critical time to prevent future suicide.”

The data of adult participants in NSDUH from the observed time period provided 484,732 persons who attempted suicide. Bommersbach et al estimated the overall annual rates of suicide attempts per 100,000 adults in the general population and from national trends for each year. They conducted subgroup analyses based on participant demographic characteristics and their clinical conditions, determining whether adjusting for such factors could account for any observed change in annual suicide attempt rates. They also examined trends in past-year mental health service use relative to past-year suicide attempts.

Approximately two-thirds of the observed survey participants were more than 35 years old (69.7%), as were those who were non-Hispanic white (65.7%). Another 51.8% were women. More than 38% were married; 31.2% had received some college education, 50.2% were employed full-time, and 44.5% lived in large metropolitan areas.

The weighted unadjusted suicide attempt rate per 100,000 persons increased from 481.2 in 2008 to 563.9 in 2019 (odds ratio [OR], 1.17; 95% CI, 1.01 – 1.36; P = .04). After controlling for sociodemographic characteristics, the increase rose to 23% (adjusted OR [aOR], 1.23; 95% CI, 1.05 – 1.44; P = .01). Multivariate analyses showed an even greater increase in suicide attempts after controlling for other significant sociodemographic and clinical factors (aOR, 1.36; 95% CI, 1.16 – 1.60; P <.001).

Suicide attempt rates particularly increased among adults aged 18 to 25 years (aOR, 1.81; 95% CI, 1.52 – 2.16; P <.001); women (aOR, 1.33; 95% CI, 1.09 – 1.62; P = .005); unemployed adults (aOR, 2.22; 95% CI, 1.58 – 3.12; P <.001); adults who never married (aOR, 1.60; 95% CI, 1.31 – 1.96; P <.001); and adults who used substances (aOR, 1.44; 95% CI, 1.19 – 1.75; P <.001).

In addition, adults with the following clinical and social characteristics and cultural groups remained independently associated with suicide attempts: serious psychological distress (aOR, 7.51; 95% CI, 6.49 – 8.68; P <.001); major depressive episodes (aOR, 2.90; 95% CI, 2.57 – 3.27; P <.001); alcohol use disorder (aOR, 1.81; 95% CI, 1.61 – 2.04; P <.001); divorced or separated (aOR, 1.65; 95% CI, 1.35 – 2.02; P <.001); Black adults (aOR, 1.41; 95% CI, 1.24 – 1.60; P <.001); American Indian, Alaska Native, Asian, or Native Hawaiian or Other Pacific Islander (aOR, 1.56; 95% CI, 1.26 – 1.93; P <.001)

Through the observed study period, 34.8% to 45.5% of adults who attempted suicide reported needing mental health care services but did not receive any. Bommersbach et al observed no significant change in the likelihood of an adult who attempted suicide receiving past-year mental health or substance-related care from 2008 to 2019.

From 2008 to 2019, the use of reasons for not seeking mental health care among adults who attempted suicide increased by 32%, per NSDUH survey responses. The reasons increased the most included: lack of transportation or services were too far away (aOR, 5.15; 95% CI, 2.35 – 11.30; P <.001); did not know where to go for treatment (aOR, 1.96; 95% CI, 1.16 – 3.32; P = .01); did not have time (aOR, 1.89; 95% CI, 0.95 – 3.75; P = .07); and did not think treatment would help (aOR, 1.61; 95% CI, 0.62 – 2.74; P = .48).

Bommersbach and colleagues noted that current US suicide prevention interventions predominately focus on individuals connected to treatment as well as those who have contact with the health care system.

“However, our finding that less than half of suicide attempters had clinical contact around the time of their attempt suggest that it is not only important to expand initiatives for high-risk individuals with clinical contact, but also to implement public health–oriented strategies outside the formal treatment system,” they wrote.

“The findings of this study suggest that suicide attempts have increased in the US in recent decades without a corresponding increase in service use among those who made such attempts,” Bommersbach et al concluded. “These data further suggest a need to expand service accessibility and/or acceptability of services as well as population-wide suicide prevention efforts.”

An earlier version of this story appeared with our sister publication 

1. Bommersbach TJ, Rosenheck RA, Rhee TG. 

National Trends of Mental Health Care Among US Adults Who Attempted Suicide in the Past 12 Months 

[published online ahead of print, 2022 Jan 19]. 

Research data have implications for prevention programs. 

Study Examines Suicide Attempts and Use of Mental Health Services

Remembering Martin Luther King 

May his words and ideals continue to inspire... 

Remembering Martin Luther King Jr in 2022

I thank Joshua Pagano, DO, for his very thoughtful and nuanced response, “

Medical Aid in Dying Allows for a Focus on Living

“Is ‘Death with Dignity’ Really Possible?”

 In essence, the response argues that physician-assisted suicide (PAS) is “…the preference of many patients with terminal illness [who wish]…to pass away peacefully while surrounded by family and friends,” and that this option provides them with “peace of mind” and “enormous comfort,” even if the patient never actually takes the lethal drug. It further asserts that “medical aid in dying has gained momentum…as many patients find it necessary to fight for the option to end their suffering…” and points to polls showing that most Americans support “medical aid in dying” or “doctor-assisted suicide.” The piece notes “…there is something distinctly different about the terminally ill person who is staring at the last 6 months of their life”—and who may be making a “rational” or “reality-based” decision to die—versus “someone suffering with mental illness.” Finally, employing a version of the Golden Rule, Pagano concludes that he could not, “…in good conscience deny someone a choice that I myself would want as an option under the same grim circumstances.”

While I appreciate Dr Pagano’s heartfelt comments, my colleagues and I reach very different conclusions on these matters, as summarized in the following paragraphs.

Voluntary Stopping of Eating and Drinking

Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. Furthermore, there is no reason to believe that the only way terminally ill patients can “pass away peacefully while surrounded by family and friends” is to ingest a lethal dose of barbiturates. For thousands of years, dying human beings have managed to die peacefully in the embrace of family and friends without recourse to “Death with Dignity” legislation. And, as I noted in my article, terminally ill patients may choose voluntary stopping of eating and drinking (VSED), which, according to a study involving hospice nurses, results in a more satisfactory death than seen with PAS. In fact, “…as compared with patients who died by PAS, those who stopped eating and drinking were rated by hospice nurses as suffering less and being more at peace in the last 2 weeks of life.”

The gentle, pastoral scene evoked in the response is far from assured, given current US procedures for PAS. One of the myths surrounding PAS is that it invariably provides a rapid, uncomplicated, and peaceful death. On the contrary, PAS is sometimes messy, prolonged, and uncomfortable. The person who ingests the lethal drug does not always “gently fall asleep.” Indeed, “Physicians who support [PAS] need to consider…the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”

Leaving aside methodological problems with the type of polls cited (for example, the 72% figure cited in the Gallup poll dropped to 65% when the question included the words, “commit suicide”), the central question is whether medical ethics ought to be governed by polls and plebiscites—or whether there are enduring and inalienable values that guide medical practice. I would ask the following: If 65% of the American public supported the euthanization of babies born with severe birth defects, would that justify the practice? Most major medical organizations—including the American Medical Association, the American College of Physicians,

 and the World Medical Association—have consistently opposed PAS on essentially ethical grounds. Recently, the College of Psychiatrists of Ireland also registered its firm opposition to PAS.

Most requests for medical aid in dying are not made by patients experiencing untreatable pain or unbearable suffering, as data from Oregon have shown. Rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).

It is not clear how genuinely rational or reality-based PAS decisions are, as Cynthia Geppert, MD, MA, MPH, MSBE, DPS, and I have discussed in our article, “

Two Misleading Myths Regarding ‘Medical Aid in Dying.

 Indeed, research has shown that some cancer patients requesting assisted suicide have subtle cognitive distortions, such as “Nobody can help me,” that are clouding their judgment.

 Thus, people who are dying may be psychologically vulnerable to coercion in ways that are not readily detected under current PAS protocols. As the College of Psychiatrists of Ireland noted, “Perceived pressures in favor of induced death can be subtle. These cannot be excluded by tests of mental capacity, such as those used in psychiatric practice.”

The issue is not, as was argued, whether it is rational to avoid foreseeable and inevitable suffering—I believe it clearly is. Rather, the issues are 1) whether physicians are morally justified in helping patients kill themselves weeks or even months before patients would otherwise die of their underlying illness; and 2) whether PAS is the only way of avoiding suffering at the end of life

 VSED is clearly an alternative to PAS that does not raise grave ethical questions for physicians, and which may result in a more peaceful death than does PAS, as noted above.

 And, contrary to a popular misconception, VSED is not starvation, since “…The body of a person who has a life-limiting illness is in the process of shutting down. They no longer require a great deal of nutrients or calories…and [do] not experience hunger or thirst in the way a healthy person does.”

Although we always aim to comfort our patients, this must be done within the constraints of sound medical practice and medical ethics. Comfort alone is not sufficient grounds for an action that may, in some important sense, be injurious to the patient—such as inducing or contributing to the patient’s death (think PAS). For example, suppose a depressed patient with chronic pain and a history of frequent 

 tells his doctor that he would find “enormous comfort” in having a large supply of oxycodone on hand “just in case I need it for pain.” This sense of comfort would hardly justify such a prescription under those conditions.

PAS does not merely allow a single individual—the patient—a choice. By legislative fiat, it entangles the physician in a bureaucratized system of assisted killing. It is true that no physician is compelled to participate directly or actually carry out PAS; however, most PAS legislation is crafted so that the refusing doctor must provide medical records to a physician who provides PAS [Annette Hanson MD, personal communication, 12/30/21]. In my view, this vitiates the first physician’s conscientious opposition to PAS and forces him or her to collude with an unethical practice.

The response states that, “Further stigmatizing those suffering with suicidal ideation in the context of mental illness in order to positively differentiate those with a terminal illness who desire medical aid in dying is not the way forward.” I am in complete agreement on this point. This is why my colleagues and I oppose the position of the American Association of Suicidology (AAS), which has tried to draw a sharp distinction between “conventional” suicide (eg, in the context of a mental illness) and what they call “physician aid in dying.”

 It is certainly true that we can discern subtypes of suicide; eg, impulsive vs planned; underlying psychiatric disorder vs reactive/situational, etc. But suicide (self-killing) is suicide regardless of the subtype.

 Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories they propose.

 We do not need a 2-tiered classification, in which there are good and bad, approved and unapproved, methods of taking one’s own life—leaving harried physicians to sort out which is which.

—one version of it, at least—seems a very decent and compassionate response. But the Golden Rule is not necessarily the best guide to medical ethics. For example, suppose we are considering the question, “Should psychiatrists be allowed to have sexual relations with their current patients?” Some might say, “Well, as a competent, consenting adult, I would want the choice of having or not having sexual relations with my psychiatrist. How, then, in good conscience, could I deny that right to someone else?” The problem, of course, is that it is a clear violation of long-established 

 for psychiatrists to have sexual relations with their patients—Golden Rule or not. It is a forbidden boundary violation.

In my view, PAS is an infinitely more egregious boundary violation, whether or not one might wish that option for oneself—and whether or not the dying patient consents to it. Indeed, a patient’s consenting to be killed does not mean a physician is ethically justified in acceding to the request.

Rather than focusing on ways to assist suicide, physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients. In closing, I thank Dr Pagano for reflecting on these difficult issues with me, and I hope he will reconsider his position in light of this response.

If a patient gives consent to be killed, is a physician ethically justified in acceding to the request?

Suicide